RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03009
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090730

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Wheeled Vehicle Mechanic, medically separated for “chronic right knee pain” with a disability rating of 10%.    

CI CONTENTION:  In addition to migraine headaches, the CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the MEB, but determined by the PEB to be not unfitting or non-compensable.  Any conditions outside the panel’s defined scope of review, and any contention not requested in this application, may remain eligible for future consideration by the Board for Correction of Military Records.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for the unfitting medical condition(s) at the time of separation.  The panel has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions; that role and authority is granted by Congress to the Department of Veterans Affairs, which operates under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20090424	VARD - 20090421	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain	5260	10%	Residuals, Right Knee ACL Tear	5260	10%	20090109	
Migraine Headaches	Not Unfitting	Migraine Headaches	8100	10%	20090109	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Right Knee Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right knee condition began in 2007 while carrying a transfer case over to a wash rack when he pulled his knee and it started to burn.  He reinjured the knee while playing flag football.  Examination of the right knee on 5 May 2008 revealed tenderness at the joint line, full range of motion (ROM) without pain and a positive apprehension test, but no instability or laxity.  An MRI demonstrated a curved anterior cruciate ligament (ACL) consistent with a partial tear and a small Baker’s cyst.  
At an orthopedic examination on 28 May 2008 revealed a 1-2 A Lachman’s test, which was symmetric to the contralateral knee, but no apprehension.  Other provocative tests for ligamentous instability were negative.  The examiner’s assessment was subjective right knee instability.  The CI was provided with an ACL brace.  

At the 9 January 2009 VA Compensation & Pension (C&P) examination, 7 months before separation, the CI reported 8/10 right knee pain exacerbated by activity, stiffness, swelling, giving way and locking.  He denied weakness, heat, redness, lack of endurance, fatigability or dislocation.  Physical examination showed a normal gait and joint line tenderness, but no edema, effusion, weakness, redness, heat or guarding of movement.  There was no locking pain, genu recurvatum (backward bending deformity) or crepitus (grinding sensation).  The ROM study showed 120 degrees of flexion (normal 140) and 0 degrees of extension (normal).  The right knee joint lost 10 additional degrees of ROM due to pain after repetition.

The 27 February 2009 MEB NARSUM examination, 5 months prior to separation, noted complaints of chronic right knee pain.  Physical examination showed a slightly antalgic gait, tenderness of the right knee joint lines and medial collateral ligament and swelling, but motor strength and sensation were normal in the lower extremities and there was no ligamentous laxity.  Moderate crepitus was noted with movement.  An MRI in March 2009 demonstrated a mild signal irregularity of the ACL, which may have represented a partial tear.  Based on the appearance, the radiologist felt it was doubtful that there would be any instability, but deferred to the physical examination of the orthopedic surgeon.  

At the 16 November 2009 VA C&P examination, less than 4 months after separation, right knee ROM measurements were 120 degrees of flexion and 0 degrees of extension, with pain.  There was no additional limitation of motion after repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB and the VA rated the right knee condition 10%, coded 5260 (leg, limitation of flexion of), citing painful motion, based on the C&P examination under the DoD/VA IDES pilot program.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under that those codes.  There was no fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was therefore no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic right knee pain.  

Contended PEB Condition:  Migraine Headaches.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement or judged to fail retention standards.  Panel members noted the CI had migraine headaches and received treatment by a neurologist once he was already in the DES, but he did not have an adequate trial of preventive medication.  Although he reported he could not concentrate or focus during a headache, there was no objective evidence of work impairment, ER visits or an MRI to corroborate the CI’s subjective symptoms.  Furthermore, there were no follow-up medical clinic or neurology visits in the STR to determine the effectiveness of treatment.  In short, there was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the right knee condition and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication.  In the matter of the contended migraine headaches, the panel recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170424, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180015367, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.